Carboxyhemoglobin as Potential Biomarker for Cardiac Surgery Associated Acute Kidney Injury.

OBJECTIVES: Carboxyhemoglobin (CO-Hb) is a marker of hemolysis and inflammation, both risk factors for cardiac surgery-associated AKI (CSA-AKI). However, the association between CO-Hb and CSA-AKI remains unknown. DESIGN: A retrospective cohort study. SETTING: Tertiary university-affiliated metropolitan hospital: single center. PARTICIPANTS: Adult on-pump cardiac surgery patients from July 2014 to June 2022 (N = 1,698). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patients were stratified into quartiles based on CO-Hb levels at intensive care unit (ICU) admission. A progressive increased risk of CSA-AKI was observed with higher CO-Hb levels at ICU admission. On multivariable logistic regression analysis, the highest quartile (CO-Hb ≥ 1.4%) showed an independent association with the occurrence of CSA-AKI (odds ratio 1.45 compared to the lowest quartile [CO-Hb < 1.0%], 95% CI 1.023-2.071; p = 0.038). Compared to patients with CO-Hb <1.4%, patients with CO-Hb ≥ 1.4% at ICU admission had significantly higher postoperative creatinine (135 vs 116 µmol/L, p < 0.001), higher rates of postoperative RRT (6.7% vs 2.3%, p < 0.001) and AKI (p < 0.001) on univariable analysis and shorter time to event for AKI or death (p < 0.001). CONCLUSIONS: CO-Hb ≥ 1.4% at ICU admission is an independent risk factor for CSA-AKI, which is easily obtainable and available on routine arterial blood gas measurements. Thus, CO-Hb may serve as a practical and biologically logical biomarker for risk stratification and population enrichment in trials of CSA-AKI prevention.

Carboxyhemoglobin in Cardiac Surgery Patients and Its Association with Risk Factors and Biomarkers of Hemolysis.

BACKGROUND: Cardiac surgery with cardiopulmonary bypass (CPB) is associated with hemolysis. Yet, there is no easily available and frequently measured marker to monitor this hemolysis. However, carboxyhemoglobin (CO-Hb), formed by the binding of carbon monoxide (a product of heme breakdown) to hemoglobin, may reflect such hemolysis. We hypothesized that CO-Hb might increase after cardiac surgery and show associations with operative risk factors and indirect markers for hemolysis. METHODS: We conducted a retrospective descriptive cohort study of data from on-pump cardiac surgery patients. We analyzed temporal changes in CO-Hb levels and applied a generalized linear model to assess patient characteristics associated with peak CO-Hb levels. Additionally, we examined their relationship with red blood cell (RBC) transfusion and bilirubin levels. RESULTS: We studied 38,487 CO-Hb measurements in 1735 patients. CO-Hb levels increased significantly after cardiac surgery, reaching a peak CO-Hb level 2.1 times higher than baseline (P < .001) at a median of 17 hours after the initiation of surgery. Several factors were independently associated with higher peak CO-Hb, including age (P < .001), preoperative respiratory disease (P = .001), New York Heart Association Class IV (P = .019), the number of packed RBC transfused (P < .001), and the duration of CPB (P = .002). Peak CO-Hb levels also significantly correlated with postoperative total bilirubin levels (Rho = 0.27, P < .001). CONCLUSIONS: CO-Hb may represent a readily obtainable and frequently measured biomarker that has a moderate association with known biomarkers of and risk factors for hemolysis in on-pump cardiac surgery patients. These findings have potential clinical implications and warrant further investigation.

Impact of COVID-19 on pediatric surgery cancellations: A retrospective study.

BACKGROUND: Prevalence trends and reasons for pediatric surgery cancellation in Japan during the coronavirus disease 2019 (COVID-19) pandemic have not previously been reported. This study aimed to compare the prevalence and reasons for cancellation of pediatric surgeries in Japan before and during the COVID-19 pandemic. METHODS: This single-center retrospective cohort study reviewed the reasons for surgery cancellations scheduled for patients aged <18 years between the prepandemic period (September 2017-December 2019) and the COVID-19 pandemic period (January 2020-April 2022). The cancellation reasons were classified into four major categories: medical, surgical, patient-related, and administrative. RESULTS: Of the 3395 and 3455 surgeries scheduled before and during the COVID-19 pandemic, 305 (9.0%) and 319 (9.2%) surgeries were canceled (p = 0.737), respectively. The proportion of cancellations due to infections or fever in medical reasons decreased from 67.9% to 56.1% (p = 0.003) and that due to patient-related reasons increased from 6.6% to 15.1% (p = 0.001). Further, the proportion of cancellations due to staff shortages in staff administrative reasons increased from 0.3% to 3.1% (p = 0.011). There was no significant difference in the proportion of surgeries canceled due to surgical reasons between the two periods. CONCLUSIONS: The proportion of cancellations due to infections or fever decreased during the COVID-19 pandemic, while that due to staff shortages increased. Infection prevention is an important measure to address the staff shortages. Implementation of national or regional policies and additional strategic interventions may be required to prepare for disasters like the COVID-19 pandemic.

Association between physicians' characteristics and their knowledge, attitudes, and practices regarding advance care planning: a cross-sectional study.

BACKGROUND: Despite physicians' vital role in advance care planning, a limited number of physicians practice it. This study assessed factors associated with physicians' knowledge, attitudes, and practices regarding advance care planning. METHODS: This cross-sectional study used data from an anonymous survey conducted by the Japanese Ministry of Health, Labour and Welfare. Questionnaires were mailed to 4500 physicians in November and December 2022. Data from 1260 respondents were analyzed. RESULTS: Of the respondents, 46.4%, 77.0%, and 82.0% reported good knowledge of advance care planning, agreed with promoting it, and with its provision by medical/care staff, respectively. Male physicians were significantly less likely to support advance care planning (odds ratio: 0.54, 95% confidence interval: 0.35-0.84) or agree to its provision by medical/care staff (odds ratio: 0.47, 95% confidence interval: 0.29-0.78) but significantly more likely to practice it (odds ratio: 1.58, 95% confidence interval: 1.05-2.36). Physicians specialized in surgery or internal/general/palliative medicine were more knowledgeable about advance care planning and more likely to practice it. Physicians working in clinics were significantly less knowledgeable (odds ratio: 0.33, 95% confidence interval: 0.25-0.44) about advance care planning and less likely to support it (odds ratio: 0.37, 95% confidence interval: 0.27-0.50), agree with its provision by medical/care staff (odds ratio: 0.54, 95% confidence interval: 0.39-0.75), or to practice it (odds ratio: 0.16, 95% confidence interval: 0.12-0.22). CONCLUSIONS: Physicians working in clinics had less knowledge of advance care planning, less supportive attitudes, and less likely to practice it. Knowledge, attitudes and practice also varied by gender and specialty. Interventions should target physicians working in clinics.

Angioleiomyoma of the right forefoot.

We describe a rare case of angioleiomyoma in the foot of a middle-aged man.

Effective Treatment of Intraoperative Hiccups With Chlorpromazine Under General Anesthesia Without Muscle Relaxants: A Case Report.

Hiccups are common reflexes and many treatment methods have been reported. Chlorpromazine is a known treatment option for hiccups, but its efficacy under general anesthesia remains unclear. We report the case of a patient with vagal schwannoma who developed hiccups while under general anesthesia. Muscle relaxants were not used because the patient was under neuromonitoring. The depth of anesthesia was deepened; however, the hiccups did not disappear. The hiccups were relieved by intravenous chlorpromazine administration (total; 5 mg), which allowed for surgery under neuromonitoring. This case indicates that chlorpromazine may be effective to treat hiccups under general anesthesia.

Development and validation of a risk score to predict the frequent emergency house calls among older people who receive regular home visits.

BACKGROUND: The demand for home healthcare is increasing in Japan, and a 24-hour on-call system could be a burden for primary care physicians. Identifying high-risk patients who need frequent emergency house calls could help physicians prepare and allocate medical resources. The aim of the present study was to develop a risk score to predict the frequent emergency house calls in patients who receive regular home visits. METHODS: We conducted a retrospective cohort study with linked medical and long-term care claims data from two Japanese cities. Participants were ≥ 65 years of age and had newly started regular home visits between July 2014 and March 2018 in Tsukuba city and between July 2012 and March 2017 in Kashiwa city. We followed up with patients a year after they began the regular home visits or until the month following the end of the regular home visits if this was completed within 1 year. We calculated the average number of emergency house calls per month by dividing the total number of emergency house calls by the number of months that each person received regular home visits (1-13 months). The primary outcome was the "frequent" emergency house calls, defined as its use once per month or more, on average, during the observation period. We used the least absolute shrinkage and selection operator (LASSO) logistic regression with 10-fold cross-validation to build the model from 19 candidate variables. The predictive performance was assessed with the area under the curve (AUC). RESULTS: Among 4888 eligible patients, frequent emergency house calls were observed in 13.0% of participants (634/4888). The risk score included three variables with the following point assignments: home oxygen therapy (3 points); long-term care need level 4-5 (1 point); cancer (4 points). While the AUC of a model that included all candidate variables was 0.734, the AUC of the 3-risk score model was 0.707, suggesting good discrimination. CONCLUSIONS: This easy-to-use risk score would be useful for assessing high-risk patients and would allow the burden on primary care physicians to be reduced through measures such as clustering high-risk patients in well-equipped medical facilities.

Giant hepatic cyst causing lower extremity edema and scoliosis.

Hepatic cysts usually do not cause symptoms and may be detected incidentally on abdominal imaging. However, a giant hepatic cyst can rarely compress the inferior vena cava, right lung, and spine, leading to edema of lower extremities and scoliosis.

Hybrid Ankle Reconstruction of Lateral Ligaments.

Open anatomic reconstruction of the lateral ligament (AntiRoLL) of the ankle with a gracilis Y graft and the inside-out technique are commonly used and have evolved to minimally invasive surgery, including arthroscopic AntiRoLL (A-AntiRoLL) and percutaneous AntiRoLL procedures. A-AntiRoLL allows assessment and treatment of intra-articular pathologies of the ankle concurrently with stabilization. However, the A-AntiRoLL technique is technically demanding, especially in the process of calcaneofibular ligament reconstruction under subtalar arthroscopy. In contrast, the percutaneous AntiRoLL procedure is a simple concept that does not require the skill of an experienced arthroscopist but requires an extra skin incision to assess and treat intra-articular pathologies of the ankle. This study describes the application of a minimally invasive anatomic reconstruction technique-hybrid AntiRoLL-for chronic instability of the ankle that does not require advanced arthroscopic technique to assess and treat intra-articular pathology simultaneously.

Early diagnosis and antibiotic treatment for fulminant Clostridium difficile infection.

In fulminant Clostridium difficile infection (CDI), early diagnosis is important, and early diagnosis could save fulminant CDI patients that do not qualify for surgery due to severe complicating conditions by conservative antibiotic therapy.

Arthroscopic ankle lateral ligament repair alone versus arthroscopic ankle lateral ligament repair with reinforcement by inferior extensor retinaculum.

PURPOSE: This study aimed to compare the clinical outcomes and postoperative activities of arthroscopic ankle lateral ligament (ALL) repair alone with arthroscopic ALL repair and reinforcement by the inferior extensor retinaculum (IER) for chronic ankle instability (CAI). MATERIALS AND METHODS: All patients who underwent arthroscopic repair for CAI between 2017 and 2019 were evaluated. The Japanese Society for Surgery of the Foot (JSSF) scale and self-administered foot evaluation questionnaire (SAFE-Q), and duration between the surgery and walking without any support, jogging, and complete return to sports were evaluated and compared. The exclusion criteria were (1) follow-up period of < 1 year after surgery, (2) the presence of associated ankle lesions requiring treatment during the same operative procedure, including patients with subfibular ossicle bigger than 5 mm on radiographs, chondral or osteochondral defect, bony impingement, deltoid ligament tear, fibular tendon pathology, or posterior ankle impingement, and (3) patients who underwent revision surgery. RESULTS: We identified 126 patients who underwent surgery for CAI and subsequently excluded 36 patients on account of a short follow-up period (< 1 year), additional surgery, and previous surgery. The remaining 90 eligible patients included arthroscopic ALL repair alone (group A, n = 44) and arthroscopic ALL repair with reinforcement by the inferior extensor retinaculum (group G, n = 46) groups. There was no significant difference in the postoperative activities nor in the preoperative or postoperative JSSF scale and SAFE-Q between the two groups. However, significant differences were seen in the mean surgical time (15.5 ± 8.1 vs 20.1 ± 7.6, P = 0.013). CONCLUSION: This study showed no difference in clinical outcomes between the two groups. However, arthroscopic ALL repair with reinforcement by IER resulted in a longer surgical time than arthroscopic ALL repair alone. LEVEL OF EVIDENCE: Retrospective comparative study, level III.

Association between Nafamostat Mesylate and In-Hospital Mortality in Patients with Coronavirus Disease 2019: A Multicenter Observational Study.

Nafamostat mesylate may be effective against coronavirus disease 2019 (COVID-19). However, it is not known whether its use is associated with reduced in-hospital mortality in clinical practice. We conducted a retrospective observational study to evaluate the effect of nafamostat mesylate in patients with COVID-19 using the Medical Data Vision Co. Ltd. hospital-based database in Japan. We compared patients with COVID-19 who were (n = 121) and were not (n = 15,738) administered nafamostat mesylate within 2 days of admission between January and December 2020. We conducted a 1:4 propensity score matching with multiple imputations for smoking status and body mass index and combined the 20 imputed propensity score-matched datasets to obtain the adjusted odds ratio for in-hospital mortality. Crude in-hospital mortality was 13.2% (16/121) and 5.0% (790/15,738), respectively. In the propensity score-matched analysis with multiple imputations, the adjusted odds ratio (use vs. no use of nafamostat mesylate) for in-hospital mortality was 1.27 (95% confidence interval: 0.61-2.64; p = 0.52). Sensitivity analyses showed similar results. The results of this retrospective observational study did not support an association between nafamostat mesylate and improved in-hospital outcomes in patients with COVID-19, although further studies with larger sample sizes are warranted to assess the generalizability of our findings.

Clinical outcomes of concurrent surgery with weight bearing after modified lasso-loop stitch arthroscopic ankle stabilization.

PURPOSE: To determine the effects of unilateral and bilateral ankle stabilization surgery with or without additional concurrent procedures for other pathologies on return to activity in patients who were allowed unrestricted weight bearing postoperatively. METHODS: Ninety-three athletes underwent 120 ankle stabilization surgeries including 27 that underwent bilateral simultaneous surgery using the all-inside arthroscopy-modified lasso-loop technique and were divided into two groups: arthroscopic ligament repair alone without concurrent procedures (group A) and with simultaneous procedures for other pathologies (group B). Group A was further subdivided into unilateral (group A1) and simultaneous bilateral ankle surgery (group A2), and group B into ankle stabilization surgery with simultaneous procedures not requiring weight bearing postoperatively (Group B1) and with concurrent procedures allowing weight bearing (Group B2). Return to activity postoperatively was assessed by recording the time to walk without any support, jog, and return to full athletic activities. Clinical outcomes were assessed preoperatively and 12 months postoperatively using a subjective clinical score. RESULTS: The average time between surgery and unsupported walk, jog, and return to full athletic activities was 1.6 ± 2.5, 16.9 ± 3.7, and 42.4 ± 19.3 days in group A, 17.2 ± 19.6, 34.5 ± 20.8, and 60.9 ± 22.8 days in group B, 1.7 ± 2.9, 16.1 ± 2.4, and 41.6 ± 18.2 days in group A1, 1.3 ± 0.6, 18.9 ± 5.5, and 44.6 ± 22.5 days in group A2, 25.3 ± 20.2, 43.3 ± 21.1, and 70.7 ± 23.1 days in group B1, and 4.8 ± 11.7, 20.7 ± 11.7, and 45.0 ± 13.7 days in group B2, respectively. These results indicate that the patients in group B2 showed a statistically significant faster time to return to activity than did those restricted from weight bearing. Differences in ankle stabilization alone between patients in groups A1 and A2 as well as groups B2 and A were not statistically significant. Clinical outcomes were similar for patients in groups B2 and A1 versus group A2. CONCLUSION: Time to return to activity and clinical outcomes after ankle stabilization surgery using the modified lasso-loop technique were negatively affected if simultaneous bilateral surgery or simultaneous concurrent procedures were added or if weight bearing was unrestricted. However, a delay in return to athletic activity was observed when ankle stabilization surgery was performed using the modified lasso-loop technique with concurrent procedures that require non-weight bearing postoperatively. LEVEL OF EVIDENCE: Level III.

Intraoperative fluid management in hepato-biliary-pancreatic operation using stroke volume variation monitoring: A single-center, open-label, randomized pilot study.

TRIAL DESIGN: This investigator-initiated, single-center, open-label, parallel-group, randomized-controlled pilot study was designed to compare the intraoperative fluid balance and perioperative complications in patients undergoing hepato-biliary-pancreatic surgery with or without stroke volume variation (SVV)-guided fluid management. METHODS: Patients who were aged >18 years and underwent elective major hepato-biliary-pancreatic surgery between June 30, 2015, and August 31, 2016 at our center were randomly assigned to receive SVV-guided or conventional fluid therapy. The intervention group used SVV to determine the patients' volume status. The primary outcome was the total fluid balance per body weight per operation time, and the secondary outcomes were the total amount of intravenous infusion per body weight per operation time and the Sequential Organ Failure Assessment score on postoperative day 1. Patients were randomized by a two-block computer-generated assignment sequence. Masking of patients and assessors was conducted. The patients and assessors were each blinded to the details of the trial; however, the clinicians were not. RESULTS: Of the 69 patients who were initially eligible, 60 provided informed consent for participation in the study. After randomization, three patients dropped out of the study because of deviations from the protocol or unexpected hypotension, leaving 28 and 29 patients in the intervention and control groups, respectively. Patients in both groups had similar characteristics at baseline. The median (interquartile range [IQR]) intraoperative fluid balance in the control and SVV groups was 6.2 (IQR, 4.9-7.9) and 8.1 (IQR, 5.7-10.5) ml/kg/h, respectively (P = .103). The administered intravenous infusion was significantly higher in the SVV group (median, 10.9; IQR, 8.3-15.3 ml/kg/h) than in the control group (median, 9.5; IQR, 7.7-10.3 ml/kg/h) (P = .011). On postoperative day 1, the PaO2/FiO2 ratio was lower in the SVV group (median, 266; IQR, 261-341) than in the control group (median, 346; IQR, 299-380) (P = .019). CONCLUSIONS: Use of the SVV-guided fluid management protocol did not reduce intraoperative fluid balance but increased the intraoperative fluid administration and might worsen postoperative oxygenation. TRIAL REGISTRATION: UMIN000018111.

Cardiac Variation of Internal Jugular Vein as a Marker of Volume Change in Hemorrhagic Shock.

BACKGROUND: Fluid resuscitation, which is critical to counter acute hemorrhagic shock, requires prompt and accurate intravascular volume estimation for optimal fluid administration. This study aimed to evaluate whether cardiac variation of internal jugular vein (IJV), evaluated by ultrasonography, could detect hypovolemic status and predict response to fluid resuscitation. METHODS: Patients undergoing autologous blood transfusion for elective surgery who were prospectively enrolled at the study blood donation center between August 2014 and January 2015. Vertical B-mode ultrasonography movies of IJV were recorded at five timepoints during blood donation: before donation, during donation, end of donation, end of fluid replacement, and after hemostasis. Cardiac variation of the IJV area and circumference were objectively measured using an automated extraction program together with blood pressure and heart rate. RESULTS: A total of 140 patients were screened, and data from 104 patients were included in the final analyses. Among the variables analyzed, only collapse index area and collapse index circumference could detect both intravascular volume loss and response to fluid administration. CONCLUSIONS: Cardiac variation of IJV may be a reliable indicator of intravascular volume loss and response to fluid administration in hemorrhagic shock.

Damage-associated molecular patterns in intensive care unit patients with acute liver injuries: A prospective cohort study.

Acute liver injury (ALI) is frequently detected in an intensive care unit (ICU) and reportedly affects prognosis. Experimental animal studies suggested that increased extracellular histone and high morbidity group box-1 (HMGB1) levels might contribute to ALI development. Whether these damage-associated molecular patterns (DAMPs) play a crucial role in ALI remains unclear in the human clinical setting.We consecutively enrolled the patients admitted to our ICU. The patients with ALI were included in the analysis together with those without ALI by using frequency matching. Extracellular histone, HMGB1, soluble thrombomodulin (sTM), and interleukin-6 (IL-6) levels were measured in plasma collected at ICU admission. ALI was defined as an acute elevation in serum aminotransferase levels to >200 IU/L.A total of 805 patients were enrolled. Twenty ALI and forty non-ALI patients were analyzed. Plasma histone levels were significantly higher in the ALI group than in the non-ALI group, whereas HMGB1 levels were significantly lower in the ALI group. Furthermore, sTM was significantly increased in the ALI patients, whereas IL-6 levels were comparable between the groups. Multivariate logistic regression analysis demonstrated that histones were independently associated with ALI. There was no significant impact of ALI on in-hospital mortality.Extracellular histones showed an independent association with ALI. Histone elevation might be one of the possible pathogenic mechanisms in the development of ALI of ICU patients.